Haemostatic changes in tall girls treated with high doses of ethinyloestradiol

Oestrogen treatment of constitutional tall stature in girls: is there a risk of thrombosis or bleeding?

AIM

To evaluate haemostatic effects and clinical outcome of oestrogen treatment of constitutionally tall stature in girls.

METHODS

We conducted a single-centre cohort study, 63 girls referred over a period of 15 years were investigated. The girls were given oestrogen treatment for constitutional tall stature at a median initial dose of 300 ug ethinyl estradiol/day and were consecutively examined for changes in coagulation. Medical records were retrospectively reviewed, additional data were collected at follow-up by blood sampling and interviews.

RESULTS

After 1 year of treatment, levels of antithrombin and von Willebrand factor (VWF) were significantly decreased (p<0.001 and p=0.015, respectively), whereas there was no significant change in levels of plasminogen inhibitor type 1. No venous thromboembolism (VTE) or major side effects were observed. Genetic risk factors for thrombosis were present, as was expected. The mean height reduction was 5.5 cm. The height-reducing effect was inversely correlated with chronological age (r=-0.44, p<0.01) and bone age (r=-0.61, p<0.01).

CONCLUSIONS

Changes in coagulation parameters occurred both towards pro- and anticoagulation. Treatment with high-dose ethinyl estradiol can successfully limit final height, and it is most effective when started at a younger bone age.

Effects of growth reduction therapy using high-dose 17beta-estradiol in 26 constitutionally tall girls

OBJECTIVE

The efficacy and safety of height-limiting therapy with high-dose 17beta-oestradiol in girls with constitutionally tall stature (CTS) are controversial. We evaluated the effectiveness of high-dose 17beta-oestradiol in premenarchal girls with CTS treated until their bone age reached 14 years.

DESIGN

We retrospectively reviewed the medical records of the girls managed between 1989 and 2000 with high-dose 17beta-estradiol for CTS with a predicted final height greater than +3SDs.

PATIENTS

Twenty-six girls met our inclusion criteria. At baseline, mean chronological age was 12.06 +/- 1.51 years and mean height was 171.1 +/- 6.5 cm with a height standard deviation score of 4.5 +/- 0.24, and mean predicted final height was 183.0 +/- 4.2 cm. Treatment was stopped when bone age reached 14 years; mean treatment duration was 1.62 +/- 0.76 years.

MEASUREMENTS

The following were obtained at 6-month intervals: height, body weight, Tanner stage, bone age, plasma cholesterol and triglycerides, plasma glucose and side effects. A mailed questionnaire on final height and satisfaction was sent 2 years after treatment discontinuation (response rate, 24/26). Results Final height was significantly (P < 0.001) reduced, by 2.4 +/- 3.2 cm, as compared to predictions. High-dose 17beta-estradiol therapy decreased growth velocity and significantly increased skeletal maturation (P < 0.001). Linear growth after treatment discontinuation was 3.3 +/- 1.9 cm. No serious side effects were recorded. Most of the patients were satisfied with the treatment.

CONCLUSION

High-dose 17beta-estradiol was moderately effective in reducing final height and should probably be reserved for selected patients, particularly as knowledge on potential long-term side effects is lacking.

Acquired protein S deficiency caused by estrogen treatment of tall stature

OBJECTIVE

To evaluate the potential thrombogenic changes in the coagulation and fibrinolytic system related to treatment with ethinyl estradiol (200 and 300 microg).

SUBJECTS AND METHODS

Twenty-five healthy girls with expected final height exceeding 185 cm, as calculated by the method of Bayley and Pinneau, were treated with 200 microg or 300 microg of ethinyl estradiol. Coagulation and fibrinolytic parameters were determined before and during estrogen treatment and 2 and 4 weeks after estrogen withdrawal.

RESULTS

No difference in the effects on hemostasis was found between the 2 treatment groups. All 25 patients developed protein S deficiency during estrogen treatment, which in most girls lasted for 4 weeks after cessation of estrogen administration. During therapy, protein C activity increased, whereas antithrombin did not change. Plasminogen and plasmin-alpha(2) antiplasmin complexes significantly increased. Protein S deficiency was accompanied by significantly increased prothrombin fragment 1+2 and fibrinopeptide A. In contrast, thrombin-antithrombin complexes did not change.

CONCLUSION

High-dose estrogen treatment to reduce the final height in tall girls is associated with a reversible acquired protein S deficiency with indications of a pre-thrombotic state. Risk of venous thrombo-embolism may be enhanced, especially when additional risk factors for thrombosis are present.

Oestrogen treatment of constitutional tall stature: a risk-benefit ratio

Oestrogens are given in high doses for the treatment of tall stature in girls. The aim of this study was to obtain data considering efficiency, side effects, and acceptance of the treatment of 50 constitutionally tall girls treated with conjugated oestrogens (7.5-11.25 mg/day). The mean (SD) adult height predictions were 188.3 (4.4) cm and the achieved height was 5.2 (3.3) cm less than the predicted height. A greater reduction from final predicted height occurred when treatment was started at an early bone age (< 13.0 years) and with a remaining growth potential of greater than 10 cm. Even postmenarcheal girls, however, had a mean reduction of 4.8 (3.2) cm. The main side effects were considerable weight gain (> 10 kg), an increase in triglyceride concentrations (37.5% of the patients), and increased platelet aggregation (60% of the patients). Altogether 84.6% of the patients were satisfied with the treatment and 15.4% regretted having had it.

Long term sequelae of sex steroid treatment in the management of constitutionally tall stature

AIM

To evaluate possible long term side effects of high doses of sex steroids in the management of constitutionally tall stature, with special attention to hypothalamic-gonadal function.

METHODS

Sixty four tall adult men and 180 tall adult women, who received supraphysiological doses of sex hormones during puberty, were interviewed in a standardised way at a mean follow up period of 10 years after cessation of treatment. Sixty one untreated tall adult men and 94 untreated tall adult women served as controls.

RESULTS

The majority of the subjects were satisfied with their decision regarding hormone treatment. Seventy seven per cent of the women and 78% of the men reported one or more side effects during treatment. Most side effects were mild. In women, only 3% stopped treatment because of an adverse event; in men, the reported side effects never stopped treatment. The frequency of reported side effects in women was higher during treatment with high doses of oestrogens than during oral contraceptive use, indicating a dose dependent relationship. Amenorrhoea of longer than six months after cessation of therapy was found in 5%. Menstrual cycle characteristics of previously treated women were comparable with controls. Malignancy was not reported. Information about a total of 127 pregnancies was obtained and revealed no distinct differences in details and outcome between previously treated women and men, and controls.

CONCLUSIONS

At a mean follow up of 10 years there is no evidence that pharmacological doses of sex hormones have a long term effect on reproductive function. However, this period is still too short to draw definite conclusions.

Severe thrombosis during oestrogen treatment for tall stature

This case report illustrates that the risk of thromboembolism in the treatment of tall girls with high dose oestrogens is not negligible.

Effects of growth hormone on the factor VIII complex in patients with growth hormone deficiency

Factor VIII activity (VIII C), factor VIII coagulant antigen (VIII C:Ag), factor VIII-related antigen (VIII R:Ag), Ristocetin cofactor (R:Cof), and growth hormone were studied in eight children with growth hormone deficiency prior to, and 60, 120, and 180 minutes after administration of human growth hormone (Crescormone, Kabi), 4 U/m2. Growth hormone has been administered for 1.0 to 6.8 years but was stopped one week prior to this investigation. Basal levels of VIII C, VIII C:Ag, VIII R:Ag, and R:Cof were within the normal limits. After administration of human growth hormone, VIII C, VIII C:Ag, VIII R:Ag, and R:Cof showed a significant rise. Our study shows that growth hormone is not necessary to maintain the basal levels of the factor VIII complex within the normal limits. However, out data suggest that growth hormone has some influences on the levels of the factor VIII complex. The mechanisms for the rise of the factor VIII complex--whether this is a direct effect of growth hormone or not--are not clear at this point.